BPH

Men’s Guide to Surgery for an Enlarged Prostate

Benign prostatic hyperplasia (BPH), is a common condition among men over 45 years of age.

It presents itself with lower urinary tract symptoms that range from mild to severe. 

A significant number of men with BPH require prostate surgery to treat or retreat their symptoms. Your doctor will determine the best treatment for the urinary symptoms. 

The treatment you receive will depend on your symptoms and availability.

What is enlarged prostate? 

Benign prostate enlargement also called BPH describes the increase in prostate volume due to the growth of prostate cells.

This walnut-sized gland is located at the base of the bladder. Prostate enlargement puts pressure on the bladder and obstructs the urethra (a duct that connects the bladder to the penis). 

Because of the location of the prostate gland, BPH is associated with urinary symptoms, including:

  • Urinary incontinence.

You may experience one two types of urinary incontinence. 

Urge incontinence: You may feel a sudden need for urination but unable to stop some leaking before you get to a toilet. 

Stress incontinence: You may leak urine due to strain such as cough or lifting objects. 

Complications of an enlarged prostate

BPH may present with sexual issues, but the mechanisms of this sexual complications are not well understood.

The assumption is that BPH symptoms cause psychological stress, which in turn magnifies sexual problems. Anxiety is associated with reduced sex drive and sexual satisfaction. 

You can also experience infections, bladder damage, or kidney damage if you develop urinary retention.

Though kidney damage is rare, men with untreated BPH have an increased risk of renal failure. It is critical to managing BPH before it causes irreparable damage to your renal function. 

The causes of an enlarged prostate are not well understood, but hormones play a critical in both prostate development and enlargement. An imbalance in the ratio of estrogen to testosterone has been linked to BPH (Prezioso et al., 2007).

Testosterone levels decrease with aging while estrogen remains unchanged or increase in men with risk factors of BPH (Hammarsten et al., 2009).

This deregulation can get worse as you age, helping drive prostate enlargement. Testosterone does not the cause BPH, but necessary for BPH to develop (Roehrborn and McConnell, 2012). 

However, despite the link between hormone levels and BPH, it is different from prostate cancer. BPH generally pose less serious health problems compared to prostate cancer

Symptoms can be similar, including raise in PSA levels. However, symptoms of an enlarged prostate are highly heterogeneous; some men experience mild symptoms, and others present with severe complications. 

Treatments for enlarged prostate 

The procedure for BPH will largely depend on the type and extent of your symptoms; typical treatment approaches are watchful waiting, lifestyle changes, and medications

In rare situations, enlarged prostate surgery is used to partly or entirely remove the prostate gland. 

Lifestyle changes

For men with mild to moderate urinary tract symptoms, watchful waiting combined with lifestyle changes is a suitable management method. 

Lifestyle changes can help relieve the symptoms of BPH. For instance, minimizing bladder irritation by reducing the intake of carbonated drinks, alcohol, and caffeine can improve your quality of life. These dietary drinks can worsen your symptoms and control your intake is useful. 

Further, reducing the fluid intake in the evening and emptying your bladder before long travels can help with urinary symptoms. 

Bladder training can give you more urinary control and reduce the impact of BPH on your daily activities.

Here, your medical provider should recommend a bladder exercise to enable you to control urine in your bladder. Finally, eating fruit and high-fiber foods can help you reduce constipation, which will, in turn, reduce pressure on your bladder and the symptoms of BPH. 

Medication for BPH

Unfortunately, your symptoms may persist even with lifestyle changes, which may require medications to treat.

Some of the drugs to treat BPH symptoms are; 

Alpha-blockers: These are pharmacological agents that relax certain muscles and keep small blood vessels open.

They specifically stop noradrenaline from tightening the muscles surrounding small arteries and veins, thereby improving blood and urine flow.

You are likely to get one of the common alpha-blockers (tamsulosin and alfuzosin). 

Anticholinergics: These inhibit the interaction binding of acetylcholine to its receptors. They reduce involuntary movements of the bladder muscle and improve urinary symptoms. 


5-alpha-reductase inhibitors: Agents to block dihydrotestosterone (anti-androgens), helping shrink the prostate gland. Anti-androgens target the growth-promoting effects of androgens. 


Diuretics: Agents to help you regulate the amount of urine produced overnight. 

If you develop chronic urine retention due to BPH may need a catheter (a thin tube) to drain their bladder. Here, a soft tube passed through your penis or small abdominal hole is used to carry urine out of your body. 

Surgical interventions 

The lifestyle changes and medications highlighted above help most men with BPH. Your symptoms may get worse, which may need a surgical treatment to resolve.

Prostate surgery to partly or entirely remove the prostate gland can treat your symptoms. The intervention will depend on the severity of your symptoms. Your doctor will help you determine the best surgery based on your circumstances.

Prostate volume (size) is a critical consideration in selecting the best surgical intervention for your BPH because complications increase with prostate volume. 

Questions to ask a doctor before surgery

As you think over the options for surgery, ask your doctor these questions:

  • Will my condition get better?


  • How much will it improve and when will you begin to feel improvement?


  • What possible side effects could occur from a treatment?


  • How long will the effects last?


  • Will I need to have this treatment repeated?

Minimally invasive surgery 

Researchers have made several attempts to develop effective minimally invasive surgical methods to treat BPH, including; 

a) Transurethral needle ablation (TUNA):

TUNA removes prostatic tissues by delivering a low radiofrequency power through a small urethral catheter inserted through the penis.

TUNA causes heat-induced coagulation necrosis (cell death) (Schulman and Zlotta, 1994). It has both reduced recovery time and fewer treatment complications.

A study that evaluated the long-term benefits of TUNA reported good clinical improvement over 5-year monitoring (Zlotta et al., 2003).

Zlotta and colleagues also showed that most men do not require additional BPH treatment in the long term. However, TUNA may be less effective than invasive surgery due to the risk of developing long-term prostate irritation and inflammation.

TUNA associated irritation and inflammation can cause urinary complications that need invasive surgery to resolve. 

b) Transurethral microwave thermotherapy (TUMT):

TUMT removes prostatic tissues by delivering microwave energy through a urethral catheter. Like TUNA, TUMT induces coagulation necrosis and has reduced recovery time (Hoffman et al., 2012).

A Cochrane review by Hoffman et al. concluded that TUMT is an effective alternative to alpha-blockers for shrinking the prostate gland.

It is especially effective in men with prostate volumes of 30 to 100ml (Hoffman et al., 2012). However, it is more suitable for men with no history of urinary retention or other prostate surgeries (Hoffman et al., 2012).

TUMT is associated with lower risks of retrograde ejaculation (ejaculating little or no semen).

There is reduced risk of transurethral resection syndrome compared to invasive surgery, but there is an increased risk of urinary retention. The pain and infection associated with urinary retention may require retreatment. 

c) High-intensity focused ultrasound (HIFU):

HIFU destroys prostatic tissues by focusing ultrasound beams through a probe inserted into the rectum. HIFU can ablate prostate tissues without damaging surrounding tissues.

Like other thermal techniques discussed above, ultrasound beams converging on the prostate gland causes heat-induced cell death, improving urine flow rate (Lü et al., 2007).

Short-term monitoring of men who received HIFU reported low complication rates, but we do not fully understand its long-term side effects and effectiveness.

Urinary and sexual problems may occur, especially in men undergoing second HIFU treatment or after other prostate procedures

d) Transurethral electrovaporization (TUEVAP):

TUEVAP vaporizes prostate tissue by heating a ball inserted through the urethra.

A study comparing TUEVAP with surgical prostate resection reported no significant difference in early postoperative morbidity or recovery time (McAllister et al., 2003). This suggests that TUEVAP is likely less beneficial in terms of reducing your risk of complications. 

e) Water-induced thermotherapy (WIT):

Water- induced therapy circulates heated water through a catheter to target thermal energy to the prostatic tissue.

WIT takes less than 1 hour to complete and has been shown to cause fewer side effects compared to other methods (Cioanta and Muschter, 2000). Like the other four thermal therapies above, WIT can be administered in an outpatient clinic, reducing the disruption to your daily routine. 

f) Urolift procedure:

Urolift is a technique that involves using implants inserted into the prostate to pull it away from the urethra. This improves urinary flow by mechanical movement, reducing the complications associated with thermal or surgical methods (Roehrborn, 2016).

Sexual issues like dry ejaculation are rare, but patients may need further treatment if the prostate continues to enlarge.

Urge incontinence, infection, and irritation may occur. However, the mechanical nature of the procedure allows you to return to normal activity within 7 days (Roehrborn, 2016).

g) Prostate artery embolization (PAE)

Prostate artery embolization is a technique that uses a special dye to identify prostate blood supply and blocks them to starve the prostate gland.

It seems to be safe, but the lack of published data makes it difficult to judge the long-term impact of the associated side-effects (Abt et al., 2018).

Most men who receive PAE for BPH have urinary improvements with reduced prostate size. Issues in finding small prostate arteries may lead to failure, requiring further invasive treatment. 

Invasive surgery 

a) Transurethral resection of the prostate (TURP):

TURP removes parts of the prostate gland through a resectoscope (a combined viewing and tissue removal thing tube) passing through the urethra.

Currently, TURP is the most effective technique for treating BPH symptoms. A common side-effect is a retrograde ejaculation, occurring in more than 80% of men treated with TURP.

You are likely to have temporary urinary incontinence some weeks after your treatment. 

b) Laser surgery:

KTP laser vaporization and holmium laser enucleation (HoLEP) uses a laser to remove the prostate tissue and treat BPH symptoms.

KTP laser vaporization uses a cystoscope inserted into your urethra to deliver pulses of laser energy to the prostate gland.

In contrast, HoLEP cuts prostatic tissues with a high-powered laser operated through the urethra. Both techniques remove excess prostate tissue that is obstructing the urethra without additional complications. 

c) Open prostatectomy:

Also called simple prostatectomy removes prostate tissues through a small incision made on your body. During the procedure, surrounding tissues may be removed, and the urethra reattached to the bladder.

Open prostatectomy can provide permanent relief for BPH symptoms. However, there is a higher risk of long-term urinary incontinence and erectile dysfunction compared to the less invasive methods above.

Erectile problems occur because all forms of prostatectomy bruise the nerves controlling erection. 

d) Transurethral incision of the prostate (TUIP):

TUIP is a procedure to treat BPH symptoms by cutting small groves at the junction of the prostate and bladder (bladder neck) (Foster et al., 2018).

The procedure is performed using a resectoscope inserted through the penis to the urethra. TUIP is minimally invasive with a lower risk of bleeding and dry ejaculation compared to prostate resection or open prostatectomy (Foster et al., 2018).

Possible dangers of TUIP include difficulty urinating, infection, and need for retreatment. 

e) Robotic prostatectomy

Robotic prostatectomy is a type of keyhole surgery to remove all or parts of the prostate gland through a small cut in the abdomen.

It is a relatively new technique, and the rate of complications depends on the number of previous cases performed by your surgeon (Novara et al., 2010).

Compared to the traditional open surgery with well-defined long-term risks, long-term side-effects in men who underwent robot-assisted surgery are not well defined. 

f) Cystoplasty:

Cystoplasty is a technique to reduce early bladder contraction by stitching intestine tissue into the bladder wall.

Cytoplasty can help you control urinary incontinence but has a double risk of complications due to performing the surgical procedure at two sites (donor and receiver sites). 

Recovery 

You might have surgery on an outpatient basis or need to be admitted in the hospital. Your doctor will discuss the exact setup depending on the intervention you will receive.

Most of these surgeries will cause swelling that will block urine flow. Thus, you are likely to have a catheter in place for up to three days post-surgery. Your medical team may need to reinsert your catheter if you continue to experience urinary problems

You might notice blood in your urine, feel an urgent or frequent need to urinate or develop urinary incontinence.

For most men, these symptoms generally clear within two weeks. Infections can develop the longer you have a urinary catheter in place.

Finally, expect to wait several weeks before you gain noticeable improvements in BPH symptoms

Improving your recovery 

Rest: You may be tempted to continue normal activities after one week, but this can hinder your recovery. Follow your post-surgery advice and take things easy at least a month, avoiding lifting or moving an object. 

Mild exercise: Try walking around to improve your blood flow and reduce the risk of a blood clot


Fluids: You can enhance urine flow by drinking plenty of fluids, majorly water, and tea. Try to avoid alcohol consumption as it can impair normal wound healing. 


Adhere to discharge information: Your medical team will tell you the best time to return to work, start driving, or start having sex following your surgery. It is better to follow their guidance and only resume these activities when you are fully recovered to avoid complications. 



Possible side effects to look out for 

The anatomical location of the prostate gland means these surgeries are likely to cause urinary tract and erection problems. 

You may notice: 

• Difficulty urinating 


• Inability to control urination 


Blood in the urine (hematuria)


Urinary tract infections 


Erectile dysfunction 


• Dry ejaculation 


• Damage to surrounding tissue 

Talking to your medical team about the possible side effects associated with each surgery is helpful. This should allow you to seek medical help if you notice anything unusual. 

Long-term monitoring 

The medications and surgical procedures to treat BPH symptoms leave most of the prostate gland untouched.

Thus, other prostate condition can develop, or BPH may reoccur. Therefore, you need to ensure yearly checks by your doctor. 

You should aim to maintain a healthy prostate, reduce prostate inflammation, and the risk of developing new prostate conditions.

A healthy diet, physical activity, and plant-based antioxidants are natural ways to reduce your risk of prostate conditions. 

Minimally invasive approaches have been developed to help reduce complications. Devices for thermal therapy, mechanical therapy, vaporization, and prostate artery embolization have proven effective in treating BPH.

They have lower complication rates and reduced recovery time. Because these techniques leave most of the prostate gland behind, your symptoms may start again. You may require more invasive treatment if you BPH returns.

Sources

  1. Abt, D., Hechelhammer, L., Müllhaupt, G., Markart, S., Güsewell, S., Kessler, T.M., Schmid, H.-P., Engeler, D.S., Mordasini, L., 2018. Comparison of prostatic artery embolisation (PAE) versus transurethral resection of the prostate (TURP) for benign prostatic hyperplasia: randomised, open label, non-inferiority trial. bmj 361, k2338.
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  6. Hammarsten, J., Damber, J.-E., Karlsson, M., Knutson, T., Ljunggren, Ö., Ohlsson, C., Peeker, R., Smith, U., Mellström, D., 2009. Insulin and free oestradiol are independent risk factors for benign prostatic hyperplasia. Prostate cancer and prostatic diseases 12, 160.
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About Our Author Dr. Chinedu Anthony Anene

Alternative Text
Dr. Chinedu Anene is a biomedical researcher, interested in the epi-genetic links between angiogenesis, cardiovascular disease, and cancer. He is interested in using bioinformatics and machine learning approaches to translate knowledge of molecular biology to disease biomarkers and novel therapeutic targets. He has expertise in preparing readily accessible reference materials.

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